HealthPartners Center for International HealthCare Delivery Model

Healthcare in the Global Village: Serving Refugees in IndianaSeptember 24-25, 2009

Patricia F Walker, MD, DTM&HAssociate Professor, Div of Infectious Disease and

International MedicineDept of Internal Medicine, University of Minnesota

Medical Director, HealthPartnersCenter for International Health and Travel Medicine

Clinics

1. Hire bilingual/ bicultural staff at all levels 2. Only use professionally trained medical interpreters 3. Hire providers with expertise in refugee health care 4. Provide multidisciplinary care

HealthPartnersCenter for International Health

Care Delivery Model:

1. Hire bilingual/ bicultural staff at all levels

HealthPartnersCenter for International Health

Care Delivery Model:

2. Only use professionally trained medical interpreters

HealthPartnersCenter for International Health

Care Delivery Model:

CIH Interpreter Vendors June 2009

Staff Interpreter49%

None Used21%

Provider Bililngual21%

Family Member1%

None Available1%

Language Line2%

Agency5%

3.Hire providers with expertise in refugee health care

HealthPartnersCenter for International Health Care Delivery Model:

4. Provide multidisciplinary care Internal Medicine Psychiatry and Psychology Co-located with Pediatrics Clinic Social Worker/Case Management staff Dietician/Diabetes educators Pharmacist

HealthPartnersCenter for International Health

Care Delivery Model:

Best Practices in New Arrival Screening

Best practice:Medical Screening of new arrivals

1. General history & physical examination2. Immunization status3. Tuberculosis screening4. Laboratory testing5. Vision and hearing evaluation6. Dentistry referral7. Psychological assessment/referral as

needed

Best Practice: Medical History

Ask the patient’s life story• Pre flight: Country of origin and reason for escape Life and employment before immigration Medical problems or stress in home country • Path to host country: Time spent in refugee camps/location Physical separation from loved ones• Losses of family/friends and reasons for death

Adams, KM et al, BMJ 328 26 June 2004

Best practice: Medical history

• History of disease or exposure:TB, malaria, parasites, hepatitis, STD’s

• Directed ROS:fever, night sweats, wt losscough, hemoptysisdiarrhea, visible parasites in stooljaundice

• Vaccine status: ask for records • Traditional medicines and substance use• Reproductive history/genital surgery/hx of UTI’s• Trauma history

Adams, KM et al, BMJ 328 26 June2004

Best Practice: Physical exam of refugees/migrants

Keep an open mind…:• Patient affect• Vision and hearing screen• Skin (pallor, tinea, nodules/macules)• Adenopathy• Chronic hearing and dental problems• Murmurs• Hepatosplenomegaly• Evidence of neuropathy• Evidence of injury/disability• Cultural practices/FGM

Courtesy of Bill Stauffer, MD

Best Practice:Tuberculosis screening for new arrivals

PPD > 6 weeks old

CXR if: Positive PPD Those with symptoms of TB disease

Use of Quantiferon Gold blood testing for patients with (+) PPDs who decline INH

Set up an LTBI clinic run by nursing staff if you do not refer patients to your health department

Best Practice: Laboratory screening

• CBC with differential• Serum chemistries• HBsAg, Hep B surface Ab, anti HBc• VDRL or RPR, HIV• Blood lead level if < 6 years old• Stool O&P x 2-3 (am specimens, different days)• Urinalysis• Screening for vaccine preventable diseases

Use best practice order sets – whether paper or electronic

         NEW ARRIVAL SCREENING (Right Click to begin documentation)       SUBJECTIVE PT NAME is a 57 yr female here for New Arrival Health

Screening. Pt here with: {COMPANION:7598}.Allergies: SOCIAL HISTORY Birth Place: {COUNTRY OF ORIGIN:19012}Year left

country of origin: ***Other countries lived in/where: ***Date US arrival: ***{ADULT/CHILD:7650}Religion: {RELIGIONS:7597}Years of formal education: {Numbers 1-10:10013}English skills: {EXCELLENT/POOR:7595}Occupation: ***

Review of Systems{ROS:16340OBJECTIVE Physical Exam:General: {general appearance:7555}Skin:

{SKIN EXAM:101::"Skin color, texture, turgor normal. No rashes or lesions."}, {EXTREMITY EXAM:5109::"extremities, peripheral pulses and reflexes normal"}, {nails:5758}HEENT: {ENT EXAM:5032::"ENT exam normal, no neck nodes or sinus tenderness"}Respiratory: {LUNG EXAM:401}Cardiovascular: {HEART EXAM:501}Breasts: {BREAST EXAM:5056::"not performed"}Gastrointestinal: {ABDOMEN:26529::"soft, without masses, distention or organomegaly","bowel sounds intact"}Genitourinary: {FEMALE/MALE:7599}Musculoskeletal: {MUSCULOSKELETAL EXAM:803}Endocrine: Thyroid exam: {thyroid:5702}Neurological: {NEURO EXAM:901::"Gait normal. Reflexes normal and symmetric. Sensation grossly intact."}Ano-Recto:

ASSESSMENT New Arrival Health Screening. Healthy appearing {CHILD:7647}***

PLAN Referral to: {new arrival referrals:7664}Orders for: ***Follow up: {REFUGEE FOLLOW UP:7730}***

US screening pitfalls

• Screening is voluntary; new arrivals may not be seen in timely fashion, or not be seen at all

• Quality and thoroughness of health assessment varies, particularly with private clinics

• Providers unfamiliar with management of results of screening

(+ PPD, eosinophilia, Hepatitis B carriers)• Reporting back to State Health Departments

is incomplete• Sharing of data nationally is incomplete

(Electronic disease notification will address this)

eSHARE: electronic system for the health assessment of refugees

Web based system for collecting domestic screening results

eSHARE tools:• Promotional materials• User Guide and Data

Dictionary• User Agreement• Implementations Models

and Protocols• Training Curriculum and

Demo Site

US screening results, selected refugee and immigrant populations

• Positive TST 10.1-70%• HBsAg (+) 4-15%• Anemia 6.6-24%• Eosinophilia 17-28%• Intestinal parasites 21-75%

Source: Seybolt L, Barnett, ED, Stauffer, W. (2007). US Medical Screening for Immigrants and Refugees. In P.F. Walker and E. D. Barnett (Ed.),

Immigrant Medicine (pp.135-150). Elsevier.

Best practices:Country/ethnic specific cancer screening

• Liver cancer Hepatitis B• Cervical cancer Human papilloma virus• Gastric cancer Helicobacter pylori

Best practices:Hepatitis B in refugees and immigrants

• High prevalence: 3 - 19% or higher • Educate carriers regarding transmission• Check Hep A status in Hep B carriers and

offer Hep A immunization if not immune• Screen family members for Hepatitis B and

offer immunization

Best practices:Hepatocellular carcinoma screening

• 3rd most common cause of cancer related deaths in world: 550K/year

• A vaccine preventable cancer

• Population specific cancer screening: AFP as tumor marker q 6 mo. RUQ US q 6-12 mo.

Best practice:Use check lists* as much as possible!

• If patient’s HBsAg is positive, have the lab automatically reflex to testing:

• Viral load• HepBeAg• HepBeAb• Hep A antibody screen• Then obtain US and send to

hepatologist

(Recommended reading: Better by Atul Gawande, MD)

Best practice: Match the cancer screening to the

population served!Cervical cancer in immigrants

• 87 yo Vietnamese patient of mine presented with vaginal bleeding. US arrival in 1985 (age 64).

• Husband had died during war, not sexually active, refused pelvic/pap.

• Dx: Stage 3 cervical cancer

Best practice:Effective educational programs

• Address cross cultural beliefs (cancer is not treatable; if I have no symptoms, I have no health problem; I am not sexually active now, and not at risk).

• Utilize female providers.• Develop ethnic specific educational

materials (Currently completing a 3 minute Spanish and Somali video for use in exam room)

• Offer HPV vaccine to younger women.

Best Practice: Consult available resources

Refugee health guidelines: www.cdc.gov/yellowbook/RefugeeGuidelines www.ccirh.uottawa.ca

Translated educational materials for the VFR traveler:www.tropical.umn.edu

The LEARN model13 min video on how to conduct an effective interview across cultures

List of excellent migrant health resources: CDC Yellow Book 2010, chapter 9 (Stauffer)